Questionnaire about your health

If you have decided to obtain a quote from Best Dental Implants Online, we advise you to fill out this questionnaire about your health, so that the most suitable dental clinic and specialists for your case can prepare the best treatment plan for you. All the information provided areÂ protected by medical confidentiality.

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First Name(s) (required)

Last Name (required)

Date of birth ( not required)

Questionnaire about your health

Do you have / did you have any of the medical conditions / diseases listed below? If yes and if necessary please write additional information.

1. Allergy (to what?)

2. Epilepsy

3. Respiratory diseases (which?)

4. Bleeding disorder

5. Diabetes (which type?)

6. Glaucoma (higher pressure int he eyes)

7. Hematologic diseases (diseases of blood producing organs)

8. Cardiovascular disease

8.1 Heart failure

8.2 Coronary heart disease / Angina pectoris

8.3Heart attack

8.4 Heart rhythm disturbances

8.5 Pacemaker

8.6 Valvular heart disease / - compensation

8.7 Hypertension (high blood pressure)

8.8 Hypertension (low blood pressure)

8.9 Hypo perfusion of the CNS/Apoplexy

9. Infections

9.1 Hepatitis

9.2 AIDS

10. Liver diseases

11. Gastro-intestinal diseases

12. Kidney disease

12.1 Chronic renal failure

12.2 Dialysis

13. Osteoporosis

14. Rheumatoid arthritis

15. Thyroid diseases

16. Tumor diseases

17. Previous operations (which?)

18. Are you afraid of the treatment?

20. Are you pregnant?

21. Do you take any medication? (all regularly taken ones, even Aspirin) (required)

22. Do you smoke? (if yes, how much/day) (required)

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